Chapter 14: Management of Common Problems

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Chapter 14 Management of Common Problems

• Bonnie M. Wivell, MS, RN, CNS

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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

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Polypharmacy (contd)

• Concurrent use of several drugs (ANA)
• Implications
• Med errors
• Non-adherence
• Drug-drug interactions
• ADRs
• Increased hospitalizations
• Risk Factors for polypharmacy
• Poor communication between physicians, number of
  co-morbidities, age-related change
• Beers list of potentially harmful drugs

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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

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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

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Falls (contd)

• 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

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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

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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

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Interventions (contd)

• 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

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Interventions (contd)

• Medication review
• Diuretics
• Narcotics
• Sedatives
• Hypnotics
• Tranquilizers
• Antidepressants
• Antihypertensives
• Laxatives
• History of drug/alcohol abuse
• Develop a Fall Prevention Plan
• Examine risk factors

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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).

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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

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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

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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

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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 patients personal space
• Deep Breathing
• Progressive Muscle Relaxation
• Cognitive Behavioral therapy
• Anxiolytics (benzos, SSRIs 1)

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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

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Assessment

• Geriatric Depression Scale
• Cornell Scale for Depression in Dementia
• Medication history
• H P

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Interventions/Strategies for Care

• Early recognition and tx can increase quantity
  and QOL
• Antidepressant medications (tricyclics, SSRIs 1)
• Psychosocial interventions
• CBT uses recognition and relaxation strategies to
  change thoughts
• Nursing interventions
• Alternative medicine
• Life review
• Socialization
• Exercise
• Community resources

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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

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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

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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

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Assessment

• Transient (acute)
• Delirium, infection, meds, stool impaction
• Established (chronic)
• Stress, urge, overflow, functional
• Evaluating bladder function
• History
• Bladder diary
• Physical
• DRE, pelvic exam
• PVR
• UA
• Cognitive status
• Environmental resources location, accessibility
  of toilet

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Stress Incontinence

• Involuntary loss of small amounts of urine during
  activities that increase intra-abdominal pressure
• Lifting, coughing, sneezing, laughing
• Causes
• Hypermobility of the bladder neck
• Urethral sphincter defects
• Weakness of pelvic floor muscles r/t pregnancy,
  multiparity, obesity, surgery, exercise,
  medications
• Treatment biofeedback, Kegels

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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

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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

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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

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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

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Mixed Incontinence

• Existence of symptoms of urge and stress at the
  same time

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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

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Interventions/Strategies for Care

• Pharmacological management
• Medications that alter detrusor muscle activity
  or bladder outlet resistance
• Surgery
• Increase bladder outlet resistance
• Remove bladder outlet obstruction
• Devices and products
• Depends, catheter supplies, urinals

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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 nights sleep only
  a few nights each month

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Types of Sleep Disturbances

• Insomnia
• Sleep apnea
• Restless leg syndrome

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Interventions/Strategies for Care

• Sleep hygiene
• Environmental restructuring
• Relaxation
• Aromatherapy
• Herbal therapy
• Medications
• Ambien
• Lunesta
• Sonata

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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

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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

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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

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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

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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.

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Ulcer Care (contd)

• 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.

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Pressure Ulcer Management

• Nutrition very important
• Protein
• Zinc
• Arginine
• Vit C, A, and B
• Tissue load management
• Positioning devices
• PUSH Tool

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Dysphagia

• Problems with swallowing that is an
  under-recognized, 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).

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Warning Signs/Risk Factors
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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

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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

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Assessment (contd)

• 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

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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

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Interventions (contd)

• 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

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Interventions (contd)

• Oral care
• Educate person and family
• Thermal stimulation - cold stimulates the swallow
  response
• Follow recommendations of speech therapist (may
  have multiple steps)

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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

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Chapter 15 Nursing Management of Dementia

• Bonnie M. Wivell, MS, RN, CNS

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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 Alzheimers)
• Interferes with a persons daily functioning
• Not considered a normal part of aging

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Types of Dementia

• Alzheimers 1
• Vascular
• Parkinsons
• 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

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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

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Causes of Dementia

• Drugs
• Environmental
• Metabolic
• Eyes/Ears sensory deprivation
• Nutrition
• Trauma/Tumor
• Infections
• Alcohol abuse or intoxication

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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, doesnt provide diagnosis

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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 1120.
  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.

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CLOCK DRAWING TEST
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Scoring of Mini-COG

• Give 1 point for each recalled word after the CDT
  distracter. Score 13.
• 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.

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Diagnosing Alzheimers

• Memory impairment alone doesnt 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!

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Diagnosing Alzheimers (contd)

• 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

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Medications for Dementia

• Medications slow progression but do not stop
  decline over time
• Cholinesterase Inhibitors (CEIs)
• donepezil (Aricept)
• rivastigmine (Exelon)
• galantamine (Razadyne)
• N-methyl-D-aspartate (NMDA) Receptor Antagonist
• memantine (Namenda) approved for moderate to late
  stage
• Anticholinergics can worsen cognitive function
• See page 540 in text

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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

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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

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Causes of Delirium

• Drugs
• Electrolytes
• Liver failure
• Infection
• Renal failure
• Impaction
• UTI or urinary retention
• Metastasis

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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

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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

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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?

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• 3. Disorganized thinking
• Is the patients 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 patients 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

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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)

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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

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Nursing Interventions/Strategies

• Use general strategies (as appear in next slides)
• Address specific issues/behaviors
• Wandering
• Aggression
• Restlessness
• Agitation
• Physical comfort
• Pain

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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.

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Pain

• Nonverbal Expressions
• Agitation/combativeness/resistance to care
• Increased confusion
• Decreased mobility
• Guarding/rubbing or holding particular body part
• Grimacing
• Restlessness
• Increase HR, Respirations

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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